Letter from the Chief Inspector of General Practice
This practice is rated as Requires Improvement overall. (Previous inspection 19 December 2016 – Inadequate)
At our inspection on 9 November 2017 we found:
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Requires Improvement
Are services responsive? – Good
Are services well-led? - Requires Improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires Improvement
People with long-term conditions – Requires Improvement
Families, children and young people – Requires Improvement
Working age people (including those recently retired and students – Requires Improvement
People whose circumstances may make them vulnerable – Requires Improvement
People experiencing poor mental health (including people with dementia) - Requires Improvement
We carried out an announced comprehensive inspection at Shrewsbury Road Surgery on 9 November 2017. We inspected the provider as part of our inspection programme, in response to concerns, to follow up on breaches of regulations.
This inspection was a follow up to earlier inspections carried out on 22 March 2016 and 19 December 2016. Following the inspection on 22 March 2016 the practice was rated inadequate in providing safe services, requires improvement in providing effective, responsive and well-led services, and good in providing caring services. It was rated requires improvement overall and there were breaches of Regulation 12 - Safe care and treatment and Regulation 17 - Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the inspection the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
We carried an inspection on 19 December 2016 to follow up on the 22 March 2016 inspection and consider whether sufficient improvements had been made for provider to meet legal requirements and associated regulations. The practice was rated inadequate in providing responsive and well-led services, requires improvement in providing safe and caring services, good in providing effective services, inadequate overall and was placed in special measures. The provider had made some improvements; however there were new breaches of Regulation 16 - Receiving and acting on complaints and continued breaches of Regulation 17 - Good governance. After the inspection the provider submitted an action plan stating how it would make further improvements and when the practice would be meeting the legal requirements and regulations.
This inspection on 9 November 2017 was an announced comprehensive inspection undertaken following the period of special measures to follow up and consider whether sufficient improvements had been made for provider to meet legal requirements and associated regulations.
Overall the practice is now rated as requires improvement.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness of the care it provided and ensured that care and treatment was delivered according to evidence- based guidelines.
- The practice had improved patient telephone and appointment access but patient survey feedback such as practice nurses care was not understood or followed up effectively.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- Evidence generally showed staff involved and treated patients with compassion, kindness, dignity and respect.
- There was a focus on continuous learning and improvement at all levels of the organisation.
- Governance systems had improved but further improvement or embedding was needed in some areas needed such as business continuity plans and quality improvement.
The areas where the provider must make improvements are:
- Establish and embed effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
An area where the practice should make improvements is:
- Seek to further understand and improve performance data for cervical screening.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice